Incidence and outcome of sars-cov-2 infection in the population undergoing dialysis treatment in lazio region

BACKGROUND AND AIMS: Patients with chronic kidney disease (CKD) represent a frail population with severe co-morbidities and different degrees of immune dysfunction. These patients might be at higher risk of SARS-CoV-2 infection and might experience severe consequences of COVID-19. In March 2020, the Lazio Regional Dialysis and Transplantation Registry (LRDTR) implemented a questionnaire to obtain information on dialysis patients who have developed SARS-CoV-2 infection. The aims of this study is to evaluate the incidence and the short-term lethality of SARS-CoV-2 infection in the population undergoing dialysis treatment in Lazio Region. METHOD: A cohort of patients treated in the dialysis units of Lazio Region was enrolled. Prevalent dialysis patients at 1/1/2020 and incident patients during the period 01/01/2020-08/01/2020 were included. The LRDTR collects information on dialysis patients from the start of chronic dialysis treatments with biannual update and immediately informing about the end of dialytic treatment (death, renal transplant, etc). Infection was traced in the LRDTR from March 2020 to 08/13/2020. The information on vital status was obtained from LRDTR and the mortality Lazio registry up to 10/30/2020. Poisson models, crude and adjusted for sex and age, were used to estimate incident rate of infection and mortality rate on dialysis patients and on dialysis patients who have developed SARS-CoV-2 infection, and respective confidence intervals of 95% (CI95%). RESULTS: During the study period, the estimate of the number of patients undergoing dialysis treatment was 5196 in Lazio Region, 65% were males with mean age of 70 years. Thirty-seven patients were infected with SARS-CoV-2: 70% males, mean age 73 years. These patients were treated in 24 different dialysis units. The cumulative incidence rate of SARS-CoV-2 infection was 0.71% (95% CI 0.52-0.98) and the adjusted incidence rate was 3.3 ∗100,000 Person Days (PD) (95% CI 2.4-4.7). The distribution of positive swabs by month was: 21 in March 7 in April, 6 in May, 1 in June, 2 in July. Twenty-seven patients had symptoms while 10 patients, who have had contact with infected individuals, had positive swabs in absence of symptoms. Infected and hospitalised dialysis patients were 78%. Of the 29 hospitalized patients: 6 were in sub-intensive care, 16 in intensive care, of these 7 needed intubations, 9 underwent non-invasive ventilation. The adjusted cumulative mortality rate in dialysis patients was 6.8% (95% CI 6.0-7.6), the same measure for SARS-CoV-2 infected patients was 37.4% (95% CI 19.8-70.4) with an average follow-up of 205 PD. The adjusted mortality rate was 3.3 ∗ 10,000PD (95% CI: 2.9-3.7) among dialysis patients and 21.2∗10,000PD (95% CI: 11.1-40.7) among infected dialysis patients. CONCLUSION: This study highlights a greater susceptibility of dialysis patients to SARS-CoV-2 infection, with a rate three times higher than that observed in the general population (source: Civil Protection Department). Mortality risk for dialysis patients with SARS-CoV-2 infection is about 6 times higher than in the dialysis patients it suggesting a major impact of infection on this fragile population.

Thyroid dysfunction in COVID-19 patients.

PURPOSE: "Non thyroidal illness syndrome" (NTIS) or "euthyroid sick syndrome" (ESS) is a possible biochemical finding in euthyroid patients with severe diseases. It is characterized by a reduction of serum T3 (fT3), sometimes followed by reduction of serum T4 (fT4). The relationship between thyroid hormones levels and mortality is well known and different studies showed a direct association between NTIS and mortality. The sudden spread of the 2019 novel coronavirus (SARS-CoV 2) infection (COVID-19) and its high mortality become a world healthcare problem. Our aim in this paper was to investigate if patients affected by COVID-19 presented NTIS and the relationship between thyroid function and severity of this infection. METHODS: We evaluated the thyroid function in two different groups of consecutive patients affected by COVID-19 with respect to a control group of euthyroid patients. Group A included patients hospitalized for COVID-19 pneumonia while patients requiring intensive care unit (ICU) for acute respiratory syndrome formed the group B. Group C identified the control group of euthyroid patients. RESULTS: Patients from group A and group B showed a statistically significant reduction in fT3 and TSH compared to group C. In group B, compared to group A, a further statistically significant reduction of fT3 and TSH was found. CONCLUSIONS: COVID-19 in-patients can present NTIS. FT3 and TSH serum levels are lower in patients with more severe symptoms.

Characteristics and outcomes of COVID-19-related hospitalization among plwh

Background: There is conflicting evidence on how HIV influences COVID19 infection. Aim of this study was to compare characteristics at presentation and clinical outcomes of people living with HIV (PLWH) versus HIV negative patients (non-PLWH) hospitalized with COVID-19. Methods: Patients ≥18 years with SARS-CoV-2 infection, defined as positive RT-PCR from nasal/oropharyngeal swab or positive serology, admitted at L. Spallanzani Institute (Italy) were included. Primary endpoint: time to invasive ventilation/death. Secondary endpoints: time to ventilation/death, time to symptoms resolution (resolution of fever or waning from oxygen). In order to control for measured confounders, Cox regression model was used. Results: A total of 905 hospitalized patients were included in the analysis (22 [2.4%] PLWH, 883 non-PLWH): 65% males, 66% with at least one comorbidity, median PaO2/FiO2 at admission 343 mmHg (260-405). PLWH were slightly younger (56 vs 62 years, p=0.057), less likely with pneumonia (59% vs 87%, p<0.001) and with PaO2/FiO2 <300 mmHg at admission (10% vs 31%, p=0.088), with less alterations in lymphocytes (1505 cells/mm vs 1170, p=0.025) and D-dimer (473 ng/mL vs 661, p=0.015) compared with non-PLWH. Symptoms at presentation were similar in the two groups apart from headache and myalgia that were more frequent in PLWH (both p<0.001). Among PLWH, nadir CD4 was 80 (33-284) cells/μl, CD4 at COVID19 diagnosis 350 cells/μl (138-515), all of them were on antiretroviral therapy and 94% had HIV-1 RNA < 50 copies/mL. The cumulative probability of invasive ventilation/death at day 14 was 9.1% (95% CI 2.4-31.7) in PLWH versus 14.7% (12.3-17.6) in non-PLWH (p=0.492). The cumulative probability of non-invasive or invasive ventilation/ death at day 14 was 14.3% (4.8-38.0) in PLWH versus 24.4% (21.4-27.8) in non-PLWH (p=0.372). Following adjustment for age, gender, comorbidities, PaO2/FiO2 and pneumonia at admission, adjusted hazard ratio (aHR) of mechanical ventilation/death of PLWH was 0.95 (95% CI 0.13-6.98, p=0.958) versus non-PLWH;similarly, aHR of non-invasive or invasive ventilation/death of PLWH was 1.05 (95% CI 0.26-4.28, p=0.947). The probability of symptoms resolution at day 14 was similar in the two groups (aHR 1.16;0.65-2.09;p=0.614). Conclusion: A less severe presentation and no difference in clinical outcomes with Covid-19 even in the adjusted models were observed in PLWH compared to non-PLWH, but further investigations are warranted due to the small sample size of HIV+ population. (Figure Presented).

An inflammatory profile correlates with decreased frequency of cytotoxic cells in coronavirus disease 2019. (COVID special issue #2.)

Increased production of inflammatory cytokines and myeloid-derived suppressor cells occurs in patients with coronavirus disease 2019. These inversely correlated with perforin-expressing natural killer (NK) and CD3⁺ T cells. We observed a lower number of perforin-expressing NK cells in intensive care unit (ICU) patients compared with non-ICU patients, suggesting an impairment of the immune cytotoxic arm as a pathogenic mechanism.

Balancing evidence and frontline experience in the early phases of the COVID-19 pandemic: current position of the Italian Society of Anti-infective Therapy (SITA) and the Italian Society of Pulmonology (SIP).

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease 2019 (COVID-19), which has rapidly become epidemic in Italy and other European countries. The disease spectrum ranges from asymptomatic/mildly symptomatic presentations to acute respiratory failure. At the present time the absolute number of severe cases requiring ventilator support is reaching or even surpassing the intensive care unit bed capacity in the most affected regions and countries. OBJECTIVES: To narratively summarize the available literature on the management of COVID-19 in order to combine current evidence and frontline opinions and to provide balanced answers to pressing clinical questions. SOURCES: Inductive PubMed search for publications relevant to the topic. CONTENT: The available literature and the authors' frontline-based opinion are summarized in brief narrative answers to selected clinical questions, with a conclusive statement provided for each answer. IMPLICATIONS: Many off-label antiviral and anti-inflammatory drugs are currently being administered to patients with COVID-19. Physicians must be aware that, as they are not supported by high-level evidence, these treatments may often be ethically justifiable only in those worsening patients unlikely to improve only with supportive care, and who cannot be enrolled onto randomized clinical trials. Access to well-designed randomized controlled trials should be expanded as much as possible because it is the most secure way to change for the better our approach to COVID-19 patients.

COVID-19, SARS and MERS: are they closely related?

BACKGROUND: The 2019 novel coronavirus (SARS-CoV-2) is a new human coronavirus which is spreading with epidemic features in China and other Asian countries; cases have also been reported worldwide. This novel coronavirus disease (COVID-19) is associated with a respiratory illness that may lead to severe pneumonia and acute respiratory distress syndrome (ARDS). Although related to the severe acute respiratory syndrome (SARS) and the Middle East respiratory syndrome (MERS), COVID-19 shows some peculiar pathogenetic, epidemiological and clinical features which to date are not completely understood. AIMS: To provide a review of the differences in pathogenesis, epidemiology and clinical features of COVID-19, SARS and MERS. SOURCES: The most recent literature in the English language regarding COVID-19 has been reviewed, and extracted data have been compared with the current scientific evidence about SARS and MERS epidemics. CONTENT: COVID-19 seems not to be very different from SARS regarding its clinical features. However, it has a fatality rate of 2.3%, lower than that of SARS (9.5%) and much lower than that of MERS (34.4%). The possibility cannot be excluded that because of the less severe clinical picture of COVID-19 it can spread in the community more easily than MERS and SARS. The actual basic reproductive number (R0) of COVID-19 (2.0-2.5) is still controversial. It is probably slightly higher than the R0 of SARS (1.7-1.9) and higher than that of MERS (<1). A gastrointestinal route of transmission for SARS-CoV-2, which has been assumed for SARS-CoV and MERS-CoV, cannot be ruled out and needs further investigation. IMPLICATIONS: There is still much more to know about COVID-19, especially as concerns mortality and its capacity to spread on a pandemic level. Nonetheless, all of the lessons we learned in the past from the SARS and MERS epidemics are the best cultural weapons with which to face this new global threat.